Damning report into infections at Glasgow's flagship hospital

A damning report's found infections at the Queen Elizabeth University Hospital contributed to the deaths of two children there.

The independent Case Note Review, led by Professor Mike Stevens, investigated 118 episodes of serious bacterial infection in 84 children and young people who received treatment for blood disease, cancer or related conditions at the Royal Hospital for Children.

It found that a third of these infections were ‘most likely’ to have been linked to the hospital environment, and that the deaths of two of the 22 children who had died were, at least in part, the result of their infection.

The infection episodes resulted in longer hospital stays for patients and the need for additional treatment, as well as delays in planned treatment in some cases.

While noting NHS Greater Glasgow & Clyde (NHS GGC) had made some improvements, the Expert Panel made 43 recommendations including improvements in environmental surveillance and how water sampling and testing are used to better inform investigations of possible links between clinical infections and water or environment sources.

Individual reports will be prepared for the families of those patients affected by the infections at the QEUH.

In addition, the Oversight Board chaired by former Chief Nursing Officer Professor Fiona McQueen has published its final report on infection prevention and control, clinical governance and communication with patients and families.

The Oversight Board acknowledges NHS GGC has taken strong remedial action to find and address water contamination issues, however it found NHS GGC’s overall response was too short-term and reactive, and there were significant failings in governance, including infection numbers and building issues not being sufficiently escalated or acted upon.

It found substantial evidence of frontline staff taking a compassionate approach to communicating with families but that this had been inconsistently applied at a Health Board level. Some patients and families felt responses to their questions about episodes of infection were not timely or informative, and they were not presented with a full and accurate picture of what was happening.

The Oversight Board’s final report recognises NHS GGC has taken a number of steps to address these issues, but concludes further work is required before it can be de-escalated from Stage 4 of NHS Scotland’s national performance framework.

Health Secretary Jeane Freeman said:

“Patients and their families should not feel unsafe in our hospitals, and staff should not be afraid to speak out as whistle-blowers if they have serious concerns. That is why I commissioned these reports alongside the Independent Review, NHS GGC’s escalation to Stage 4, and the Public Inquiry that is now underway, so that the issues raised could be fully investigated.

While the report does not name the children, the parents of Milly Main believes the patient referenced is her daughter, who died in 2017.

Her case came to light when whistleblowers claimed a child with cancer died after contracting an infection caused by the contaminated water supply at the QEUH campus.

Her mother Kimberly Darroch said: “There is nothing that can bring Milly back and a tiny part of me still hoped that the link to the water supply wasn’t true.

“Finally we are starting to get answers after all these years.

“If it wasn’t for the whistleblowers who came forward and Anas Saywar raising this in Parliament, we would have never known what caused Milly’s death.

“This has been a difficult time for us and we will need to come to terms with this as a family.”

In response, the NHS Greater Glasgow and Clyde Health board said: " This has been an incredibly difficult period for patients, families and staff and we are very sorry for the distress caused. For those whose infection episodes were judged by the Case Note Review panel to be possibly or probably linked to the hospital environment, we apologise unreservedly.

The question over potential links between the hospital environment and infections amongst young patients treated in RHC haemato-oncology unit has persisted for a number of years. As the two reports published today have highlighted, this has been a very difficult question to answer.

Whilst it has not been possible to provide conclusive answers to these questions, significant action has been taken to mitigate the risk of infection from the environment. As soon as we recognised the potential risks with the water supply in 2018, we took action. This included point of use filters for water outlets, chlorination treatment of the water supply, and ultimately the relocation of Wards 2A and B to another part of the hospital.

In total, £6million was spent on addressing water supply issues. In addition, a further £8million has been invested in Wards 2A and B, including a significant upgrade of the ventilation system. This will deliver the one of the safest clinical environments within the UK and with the improvements that have already been made and continue to be made, infection rates at the hospital remain low.

Over the past year we have also worked closely with the Oversight Board and with Professor Angela Wallace, appointed by the Scottish Government as Interim Director of Infection Prevention and Control.

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